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NO GOOD TREATMENT FOR LICHEN SCLEROSIS

Q: Recently I was diagnosed with vulvar lichen sclerosis. I had the shiny white bumps three years ago, and the doctor said I had a yeast infection. I have passed that stage and now have black patches.

A gynecologist is now treating me with a testosterone cream. I have read that a potent corticosteroid cream is the way to go. What can you tell me about that?

- Anonymous, Jennings, La.

A: Lichen sclerosis (full name, lichen sclerosis et atrophicus) is an inflammatory disease of the skin and mucous membranes. Lichenification means a thickening of skin or mucous membranes with accompanying deep grooves and wrinkles. Sclerosis means a hardening of involved tissue usually associated with inflammation (e.g., atherosclerosis is also called hardening of the arteries).

The disorder most often affects the genitalia of adult women, but it can also occur in men and children. It occurs most commonly in women at times of low sex hormone output, typically after menopause.

Any skin site may be affected. But lichen sclerosis is most common in the anogenital area, where it causes moderate to severe itching and soreness. Lichen sclerosis can also occur without the symptoms of itching and soreness.

The primary lesions of lichen sclerosis are small, raised white areas with a red halo. Often dark, hard plugs occur in the center where a hair follicle used to be. The surrounding area may be white and crinkled. Progression to destructive scarring is common. There is an increased risk in women of developing cancer of the vulva and in men developing penile cancer.

One medical study reported that in a majority of women lichen sclerosis causes a negative effect on their sexual function, including painful intercourse and difficulty achieving orgasm.

There are no reported studies on the negative impact of lichen sclerosis on conceiving or delivering children. But the swollen vulvar tissue and scarring may present physical problems at delivery.

The underlying cause is unknown, but there seems to be genetic abnormality of the immune system. Lichen sclerosis often occurs in skin already scarred or damaged, so trauma and injury have been suggested as possible triggers of symptoms in genetically predisposed people. Viruses may also trigger the problem.

Because a number of disorders have similar symptoms, diagnosis is not always easy.

A closely related problem is lichen planus, which shares common clinical and pathological features. This includes involvement of both skin and mucous membranes, erosive mucosal lesions, and the occasional occurrence of skin cancer at the sites of erosion. Making the correct diagnosis requires examination of biopsied tissue under a microscope.

There are no good treatments for this condition. But the treatment of choice is a potent topical corticosteroid ointment. New treatments are under investigation, one of which is the use of calcitriol (a vitamin D related chemical). In difficult cases, circumcision may be indicated in men, and surgery may be considered in women to relieve effects of scarring or to treat possible coexisting cancer.